‘Tired all the time’ and Chronic Fatigue Syndrome

Why?

• Common

• Trials show poor patient satisfaction• Poorly understood • CFS recent media coverage• CFS is recognized by NICE as real and defined by

WHO as a neurological illness (G93.3) but many differing attitudes of doctors, public and patients…

‘oh - is that the thing that makes people lazy?’

Content

• TATT• Diagnosis• Investigations

• Chronic fatigue• Diagnosis• Investigations• Management

Tired all the time

• Common

• Average 30 patients/yr per GP

• Most common ‘unexplained complaint’• Underlying factors….

• Physical in ~9%

• Psychological in up to 75%

History and Examination• Onset and duration and pattern of fatigue

• Shorter duration suggests post-viral • On exertion relieved by rest suggests organic• Worst in morning ? depression

• Sleep pattern• EMW/ unrefreshing sleep ? depression• Snoring/ day-time sleeping ? sleep apnoea

• Associated symptoms• SOB/ weight loss/ anorexia/ pain

• Psychiatric symptoms• Depression/ anxiety/ stress

• Alcohol/ drugs/ OTC• Patient’s views/ worries• Mental state exam• Physical examination usually normal

Prediction of outcome in patients presenting

with fatigue in primary care (BJGP 2009)

• Prospective cohort study n=642• Adverse prognostic factors for chronicity

• Severity of fatigue and associated pain

• Expectation of chronicity

• Less social support

• Patient expectation of chronicity especially predicted negative outcomes

• Enjoying daily activities associated with positive outcome• ?potentially modifiable patient expectations leading to better

outcome.

Differential Diagnosis TATT

• Depression• Asthma• DM• Hypo/hyperthyroidism• Anaemia• Sleep apnoea• Infection e.g.

CMV/EBV/Hepatitis

• Neurological e.g. MS• Connective Tissue e.g.

RA/SLE• Peri-menopausal• Malignancy• Chronic Fatigue

Investigations

• Led by history/ examination• Oxford Handbook suggest if ‘sustained’ fatigue with no obvious

cause check…

• Urinalysis

• FBC/ PV/ CRP/ U&E/ LFT/ Calcium/ TFT/ Glu/ CK/ Coeliac

• Ferritin in young people

• +/- serological viral tests EBV/CMV

VAMPIRE Study (BJGP 2009)

• VAgue Medical Problems In Research Trial• GP presentations with unexplainable fatigue n=325

• Wait at least 4 weeks

• 78% did not represent for bloods• 8% patients tested had abnormalities • Limited blood set picked up most conditions

• FBC/PV/Glu/TSH

• DM most common then anaemia/ EBV

Chronic Fatigue Syndrome (ME)

• Female:Male 4:1

• Most common 40-50yrs

• NICE Clinical Guideline 53 - 2007

Definition• Symptoms present for at least 4 months (3 in kids)• May fluctuate in severity and change in nature

over time• Other diagnoses excluded• Reconsider if none of 4 key symptoms• 1) FATIGUE

• New or specific onset• Persistent and/or recurrent• Unexplained by other conditions• Substantial reduction in activity level• Post-exertional malaise and/or fatigue

• 2) One or more of….

• Sleep disturbance• Muscle or joint pain• Cognitive dysfunction • Headaches• Painful lymph nodes without enlargement• Sore throat• Physical or mental exertion makes symptoms worse• ‘flu-like’ symptoms• Dizziness and/or nausea• Palpitations in the absence of cardiac pathology

Severity

• Mild• Mobile• Self caring• Light domestic tasks with difficulty• Still working but days off• Stopped leisure/social activities

• Moderate• Reduced mobility• Restricted in all activities daily living• Usually stopped work• Need rest periods• Poor/ disturbed sleep

• Severe• Unable to do any activity for themselves or

carry out minimal activities e.g face washing• Severe cognitive difficulties• Wheelchair bound• Often housebound• Sensitive to light and noise

Aetiology

• Poorly understood - lots of theories• Viral• Genetic• Immunological• Neuro-endocrine• Psychological

• Best regarded as a spectrum

Investigations

• FBC• UE• LFT• TFT• CRP• PV• Urinalysis• Glucose• Coeliac serology• Calcium• CK

• Not unless indicated…

• Ferritin unless young

• Viral serology

• B12/ folate

General management

• Coordinated by named professional• Shared decision making• Individualized management plan• Access to community services

• Occupational• Social care

• Regular structured review• Specialist referral if required

Drug therapy

• No firm evidence for any• Consider SSRI if mood symptoms• Consider low dose TCA if pain/ sleep problems• Little evidence for….

• Anticholinergics• Steroids• Antivirals• Dexamphetamine• MAOIs

• No evidence for requiring reduced dose

Non drug treatment

• Discourage rest periods > 30minutes• Cognitive Behavioural Therapy

• Reduces symptoms• Increases functioning• Increases QOL

• Graded Exercise Therapy• Evidence for increased functioning• NOT just ‘exercise more’

QuickTime™ and a decompressor

are needed to see this picture.

Others - little evidence but may help

• Sleep Management• Relaxation• Pacing

• Activity Management• Exclusion diets

Setbacks in recovery

• Expect them• Triggers

• Poor sleep/ increase in activity/ stress• Infections/ other illness

• Should have a clear plan including rests and when to cut activities

Prognosis

• Most improve over time• Only 5-10% achieve complete recovery to

former levels despite remission • Some relapse

• Should have planned setback strategies

• Small number remain severely affected

Summary

• Delay Ix for 4 weeks• Simple bloods only• Chronic fatigue is a spectrum but still

poorly understood. • Best evidence is for Graded Exercise/CBT

Any questions?